H’s and T’s

As you are moving through your algorithms during ACLS and PALS, it is important to also consider reversible causes for the emergent condition. Pulseless electrical activity (PEA), asystole, ventricular fibrillation (VFib or VF), and ventricular tachycardia (VTach or VT) may have a reversible cause in your patient (though most often PEA). The reversible causes of PEA can be remembered with a mnemonic of sorts, the H’s and T’s.

The H’s and T’s are 12 reversible conditions, 7 that start with H and 5 that start with T.

Hypovolemia

Hypoxia

Hydrogen ion excess (acidosis)

Hypoglycemia

Hypokalemia

Hyperkalemia

Hypothermia

Tension pneumothorax

Tamponade – Cardiac

Toxins

Thrombosis (pulmonary embolus)

Thrombosis (myocardial infarction)

While it is important to continue to deliver compressions, ventilation, and medications according to the algorithm, it is always best to treat underlying causes of PEA and related conditions as soon as possible.

Typically will be seen as a prolonged QT interval on the ECG; may see neurological symptoms

Based on the specific toxin

Thrombosis (pulmonary embolus)

Rapid heart rate with narrow QRS complexes on the ECG

Surgical embolectomy or administration of fibrinolytics

Thrombosis (myocardial infarction)

ECG will be abnormal based on the location of the infarction

Dependent on extent and age of MI

*Hypoglycemia is not officially one of the H’s and T’s for adults, but it still can be an important cause of PEA, especially in children. If another reversible cause has not been discovered or if the patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of insulin) then this potential cause of PEA should be considered.

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